In his review article, "Euthanasia: Historical, Ethical, and Empiric Perspectives," Emanuel1 ignores the crucial distinction between request and refusal that gives moral significance to the distinction between active and passive euthanasia.

In discussing his table of definitions, Emanuel says:

... what distinguishes voluntary active euthanasia from either passive or indirect euthanasia is the intention of the physician. In the former case, the physician intends to end the life of the patient, while in the latter two cases the physician intends something else, such as relieving pain or withdrawing intrusive medical interventions.

We believe that this is mistaken. The intention of the physician is not what distinguishes voluntary active euthanasia from voluntary passive euthanasia (terminating life-sustaining medical treatments). The crucial moral distinction is that between a patient refusal and a patient request. When a competent patient rationally refuses a medical treatment, a physician is both morally and legally required to abide